1
|
Dong Z, Zhang W, Sun W, Zhang S, Yang C, Wu C, Fan L. Paradoxical development of pleural-based masses in patients with pleural tuberculosis during treatment: a clinical observational study in China. BMC Pulm Med 2022; 22:126. [PMID: 35379218 PMCID: PMC8981736 DOI: 10.1186/s12890-022-01910-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Accepted: 03/23/2022] [Indexed: 11/10/2022] Open
Abstract
Background To explored the clinical, pathological, and bacteriological characteristics of pleural-based masses occurred during anti-tuberculosis (TB) treatment in patients with pleural TB. Methods Patients referred with newly diagnosed pleural TB were prospectively enrolled into the study. Patients were followed up throughout the treatment, and clinical data were recorded. Percutaneous biopsy and surgical tissues from pleural-based masses were examined histologically and samples sent for PCR. Cytokines in the pleural effusions and clinical factors were collected and compared between different patients. Results A total of 122 patients with pleural TB were enrolled, and 34.4% (42/122) displayed newly observed pleural-based mass during the treatment. Twelve cases underwent surgical resection at the 12 ± 0.5 months during the treatment course. Based on the surgical observation, 58.3% (7 /12) were located in pleura, 41.7% (5/12) were located in the lung parenchyma. Pathological observations showed that the pleural-based masses were typed as granulomatous inflammation, fibrous hyperplasia and necrosis. Mycobacterium tuberculosis PCR was positive in 57.1% of the cases (24/42). Any first-line anti-TB drug resistance gene mutations were positive in only 9.5% (4/42). Aside from 12 cases who underwent the surgical operation, 86.7% of the patients (26/30) still had a pleural-based mass at the end of 12 months treatment course. Patients with a pleural-based mass were younger, had a thicker pleural, a higher proportion of pleural adhesive, loculated pleural effusion and residual pleural effusion, and a higher level of LDH, ADA and lower glucose in pleural effusion than those without a pleural-based mass occurrence during the treatment (all Pcorr < 0.05). Conclusions Pleural-based masses were observed in about one-third of patients with pleural TB. The masses were in the lung or pleura and were divided into three pathological types. Supplementary Information The online version contains supplementary material available at 10.1186/s12890-022-01910-6.
Collapse
Affiliation(s)
- Zhengwei Dong
- Department of Pathology, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, 200433, China
| | - Wei Zhang
- Department of Pathology, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, 200433, China
| | - Wenwen Sun
- Clinic and Research Center of Tuberculosis, Shanghai Key Lab of Tuberculosis, Shanghai Pulmonary Hospital, Tongji University School of Medicine, No. 507 Zhengmin Road, Yangpu District, Shanghai, 200433, China
| | - Shaojun Zhang
- Clinic and Research Center of Tuberculosis, Shanghai Key Lab of Tuberculosis, Shanghai Pulmonary Hospital, Tongji University School of Medicine, No. 507 Zhengmin Road, Yangpu District, Shanghai, 200433, China
| | - Chenlu Yang
- Department of Thoracic Surgery, Tongji University School of Medicine, Shanghai Pulmonary Hospital, Shanghai, China
| | - Chunyan Wu
- Department of Pathology, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, 200433, China.
| | - Lin Fan
- Clinic and Research Center of Tuberculosis, Shanghai Key Lab of Tuberculosis, Shanghai Pulmonary Hospital, Tongji University School of Medicine, No. 507 Zhengmin Road, Yangpu District, Shanghai, 200433, China.
| |
Collapse
|
2
|
Requena-Méndez A, Davies G, Waterhouse D, Ardrey A, Jave O, López-Romero SL, Ward SA, Moore DAJ. Intra-individual effects of food upon the pharmacokinetics of rifampicin and isoniazid. J Antimicrob Chemother 2020; 74:416-424. [PMID: 30412245 DOI: 10.1093/jac/dky444] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2018] [Accepted: 10/01/2018] [Indexed: 01/21/2023] Open
Abstract
Background Poor response to TB therapy might be attributable to subtherapeutic levels in drug-compliant patients. Pharmacokinetic parameters can be affected by comorbidities or the interaction of drugs with food. Objectives This study aimed to determine the effect of food intake upon pharmacokinetics of rifampicin and isoniazid in a Peruvian population with TB. Methods Rifampicin and isoniazid levels were analysed at 2, 4 and 6 h after drug intake in both fasting and non-fasting states using LC-MS methods. Results Sixty patients participated in the study. The median rifampicin Cmax and AUC0-6 were higher during fasting than non-fasting: 7.02 versus 6.59 mg/L (P = 0.054) and 28.64 versus 24.31 mg·h/L (P = 0.002). There was a statistically significant delay overall of non-fasting Tmax compared with the fasting state Tmax (P = 0.005). In the multivariate analysis, besides the effect of fasting, Cmax for females was 20% higher than for males (P = 0.03). Concerning isoniazid, there were significant differences in the Cmax during non-fasting (median = 3.51 mg/L) compared with fasting (4.54 mg/L). The isoniazid dose received had an effect upon the isoniazid levels (1.26, P = 0.038). In the multivariate analysis, isoniazid exposure during fasting was found to be 14% higher than during non-fasting (CI = 1.02-1.28, P < 0.001). Neither radiological extent of the disease nor consumption of food with drug intake nor pharmacokinetics of rifampicin or isoniazid was associated with a poorer treatment outcome. Conclusions Rifampicin in particular and isoniazid pharmacokinetics were significantly affected by the intake of the drug with food between and within individuals.
Collapse
Affiliation(s)
- Ana Requena-Méndez
- Barcelona Institute for Global Health (ISGlobal-CRESIB), Hospital Clinic-Universitat de Barcelona, Barcelona, Spain
| | - Geraint Davies
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - David Waterhouse
- Department of Molecular Parasitology, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Alison Ardrey
- Department of Molecular Parasitology, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Oswaldo Jave
- Servicio de Pneumología, Hospital Dos de Mayo, Lima, Peru
| | - Sonia Llanet López-Romero
- Laboratorio de Investigación de Enfermedades Infecciosas, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Stephen A Ward
- Department of Molecular Parasitology, Liverpool School of Tropical Medicine, Liverpool, UK
| | - David A J Moore
- TB Centre and Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| |
Collapse
|
3
|
Nabisere R, Musaazi J, Denti P, Aber F, Lamorde M, Dooley KE, Aarnoutse R, Sloan DJ, Sekaggya-Wiltshire C. Pharmacokinetics, SAfety/tolerability, and EFficacy of high-dose RIFampicin in tuberculosis-HIV co-infected patients on efavirenz- or dolutegravir-based antiretroviral therapy: study protocol for an open-label, phase II clinical trial (SAEFRIF). Trials 2020; 21:181. [PMID: 32054536 PMCID: PMC7020342 DOI: 10.1186/s13063-020-4132-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Accepted: 02/01/2020] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Tuberculosis (TB) is a significant public health problem that causes substantial morbidity and mortality. Current first-line anti-TB chemotherapy, although very effective, has limitations including long-treatment duration with a possibility of non-adherence, drug interactions, and toxicities. Dose escalation of rifampicin, an important drug within the regimen, has been proposed as a potential route to higher treatment efficacy with shorter duration and some studies have suggested that dose escalation is safe; however, these have almost entirely been conducted among human immunodeficiency (HIV)-negative TB patients. TB-HIV co-infected patients on antiretroviral therapy (ART) are at increased risk of drug-drug interactions and drug-related toxicities. This study aims to determine the safety of higher doses of rifampicin and its effect on the pharmacokinetics of efavirenz (EFV) and dolutegravir (DTG) in TB-HIV co-infected patients. METHODS This study is a randomized, open-label, phase IIb clinical trial among TB-HIV infected adult outpatients attending an HIV clinic in Kampala, Uganda. Patients newly diagnosed with TB will be randomized to either standard-dose or high-dose rifampicin (35 mg/kg) alongside standard TB treatment. ART-naïve patients will be randomly assigned to first-line ART regimens (DTG or EFV). Those who are already on ART (DTG or EFV) at enrollment will be continued on the same ART regimen but with dose adjustment of DTG to twice daily dosing. Participants will be followed every 2 weeks with assessment for toxicities at each visit and measurement of drug concentrations at week 6. At the end of intensive-phase therapy (8 weeks), all participants will be initiated on continuation-phase treatment using standard-dose rifampicin and isoniazid. DISCUSSION This study should avail us with evidence about the effect of higher doses of rifampicin on the pharmacokinetics of EFV and DTG among TB-HIV co-infected patients. The trial should also help us to understand safety concerns of high-dose rifampicin among this vulnerable cohort. TRIAL REGISTRATION ClinicalTrials.gov, ID: NCT03982277. Registered retrospectively on 11 June 2019.
Collapse
Affiliation(s)
- Ruth Nabisere
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Joseph Musaazi
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Paolo Denti
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Florence Aber
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Mohammed Lamorde
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Kelly E Dooley
- Division of Clinical Pharmacology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Derek J Sloan
- Division of Infection and Global Health, School of Medicine, University of St. Andrews, St. Andrews, Scotland
| | | |
Collapse
|
4
|
Cresswell FV, Te Brake L, Atherton R, Ruslami R, Dooley KE, Aarnoutse R, Van Crevel R. Intensified antibiotic treatment of tuberculosis meningitis. Expert Rev Clin Pharmacol 2019; 12:267-288. [PMID: 30474434 DOI: 10.1080/17512433.2019.1552831] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Meningitis is the most severe manifestation of tuberculosis, resulting in death or disability in over 50% of those affected, with even higher morbidity and mortality among patients with HIV or drug resistance. Antimicrobial treatment of Tuberculous meningitis (TBM) is similar to treatment of pulmonary tuberculosis, although some drugs show poor central nervous system penetration. Therefore, intensification of antibiotic treatment may improve TBM treatment outcomes. Areas covered: In this review, we address three main areas: available data for old and new anti-tuberculous agents; intensified treatment in specific patient groups like HIV co-infection, drug-resistance, and children; and optimal research strategies. Expert commentary: There is good evidence from preclinical, clinical, and modeling studies to support the use of high-dose rifampicin in TBM, likely to be at least 30 mg/kg. Higher dose isoniazid could be beneficial, especially in rapid acetylators. The role of other first and second line drugs is unclear, but observational data suggest that linezolid, which has good brain penetration, may be beneficial. We advocate the use of molecular pharmacological approaches, physiologically based pharmacokinetic modeling and pharmacokinetic-pharmacodynamic studies to define optimal regimens to be tested in clinical trials. Exciting data from recent studies hold promise for improved regimens and better clinical outcomes in future.
Collapse
Affiliation(s)
- Fiona V Cresswell
- a Clinical Research Department , London School of Hygiene and Tropical Medicine , London , UK.,b Research Department , Infectious Diseases Institute , Kampala , Uganda
| | - Lindsey Te Brake
- c Department of Pharmacy , Radboud Institute of Health Sciences, Radboud Center for Infectious Diseases Radboud university medical center , Nijmegen , The Netherlands
| | - Rachel Atherton
- b Research Department , Infectious Diseases Institute , Kampala , Uganda
| | - Rovina Ruslami
- d TB-HIV Research Centre, Faculty of Medicine , Universitas Padjadjaran , Bandung , Indonesia
| | - Kelly E Dooley
- e Divisions of Clinical Pharmacology and Infectious Diseases, Department of Medicine , Johns Hopkins University School of Medicine , Baltimore , MD , USA
| | - Rob Aarnoutse
- c Department of Pharmacy , Radboud Institute of Health Sciences, Radboud Center for Infectious Diseases Radboud university medical center , Nijmegen , The Netherlands
| | - Reinout Van Crevel
- f Department of Internal Medicine and Radboud Center for Infectious Diseases , Radboud university medical center , Nijmegen , the Netherlands.,g Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine , University of Oxford , Oxford , UK
| |
Collapse
|
5
|
Pettit AC, Shepherd BE, Sterling TR. Treatment of drug-susceptible tuberculosis among people living with human immunodeficiency virus infection: an update. Curr Opin HIV AIDS 2018; 13:469-477. [PMID: 30222609 PMCID: PMC6389504 DOI: 10.1097/coh.0000000000000506] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW The present review describes recent advances in the treatment of drug-susceptible tuberculosis (DS-TB) among people living with human immunodeficiency virus (PLWH). RECENT FINDINGS Higher than standard rifampicin doses (>10 mg/kg/day) are well tolerated and have improved sterilizing activity. Standard pyrazinamide doses may result in low drug exposures; modeling reveals that higher doses (>25 mg/kg/day) may be required to reach target levels, although safety is unknown. Four-month fluoroquinolone-containing regimens are not recommended in the 2017 World Health Organization DS-TB treatment guidelines. These guidelines also recommend fixed-dose combination (FDC) therapy over single drug formulations based on patient preference, though FDC is not associated with improved outcomes. Treatment for 6 months is recommended, with an emphasis on expanded antiretroviral therapy (ART) coverage and monitoring for relapse among those not started on ART within 8 weeks of tuberculosis treatment. Directly observed therapy (DOT) is recommended over self-administered therapy, as is daily therapy over intermittent therapy - both are associated with better tuberculosis outcomes. SUMMARY Current WHO tuberculosis treatment guidelines recommend 6 months of daily tuberculosis treatment for PLWH who have DS-TB, and timely ART initiation. Higher rifampin and pyrazinamide doses may enhance treatment effectiveness, but safety data are needed. DOT and FDC therapy are recommended.
Collapse
Affiliation(s)
- April C. Pettit
- Division of Infectious Diseases, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Vanderbilt Tuberculosis Center, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Bryan E. Shepherd
- Vanderbilt Tuberculosis Center, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Timothy R. Sterling
- Division of Infectious Diseases, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Vanderbilt Tuberculosis Center, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| |
Collapse
|
6
|
Sekaggya-Wiltshire C, von Braun A, Lamorde M, Ledergerber B, Buzibye A, Henning L, Musaazi J, Gutteck U, Denti P, de Kock M, Jetter A, Byakika-Kibwika P, Eberhard N, Matovu J, Joloba M, Muller D, Manabe YC, Kamya MR, Corti N, Kambugu A, Castelnuovo B, Fehr JS. Delayed Sputum Culture Conversion in Tuberculosis-Human Immunodeficiency Virus-Coinfected Patients With Low Isoniazid and Rifampicin Concentrations. Clin Infect Dis 2018; 67:708-716. [PMID: 29514175 PMCID: PMC6094003 DOI: 10.1093/cid/ciy179] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2017] [Accepted: 03/01/2018] [Indexed: 01/23/2023] Open
Abstract
Background The relationship between concentrations of antituberculosis drugs, sputum culture conversion, and treatment outcome remains unclear. We sought to determine the association between antituberculosis drug concentrations and sputum conversion among patients coinfected with tuberculosis and human immunodeficiency virus (HIV) and receiving first-line antituberculosis drugs. Methods We enrolled HIV-infected Ugandans with pulmonary tuberculosis. Estimation of first-line antituberculosis drug concentrations was performed 1, 2, and 4 hours after drug intake at 2, 8, and 24 weeks of tuberculosis treatment. Serial sputum cultures were performed at each visit. Time-to-event analysis was used to determine factors associated with sputum culture conversion. Results We enrolled 268 HIV-infected patients. Patients with low isoniazid and rifampicin concentrations were less likely to have sputum culture conversion before the end of tuberculosis treatment (hazard ratio, 0.54; 95% confidence interval, .37-.77; P = .001) or by the end of follow-up (0.61; .44-.85; P = .003). Patients in the highest quartile for area under the rifampicin and isoniazid concentration-time curves for were twice as likely to experience sputum conversion than those in the lowest quartile. Rifampicin and isoniazid concentrations below the thresholds and weight <55 kg were both risk factors for unfavorable tuberculosis treatment outcomes. Only 4.4% of the participants had treatment failure. Conclusion Although low antituberculosis drug concentrations did not translate to a high proportion of patients with treatment failure, the association between low concentrations of rifampicin and isoniazid and delayed culture conversion may have implications for tuberculosis transmission. Clinical Trials Registration: NCT01782950.
Collapse
Affiliation(s)
| | - Amrei von Braun
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Switzerland
| | - Mohammed Lamorde
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Bruno Ledergerber
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Switzerland
| | - Allan Buzibye
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Lars Henning
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Switzerland
- Division of Tropical Health and Medicine, James Cook University, Queensland, Australia
| | - Joseph Musaazi
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Ursula Gutteck
- Department of Clinical Chemistry, University Hospital Zurich, University of Zurich, Switzerland
| | - Paolo Denti
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, South Africa
| | - Miné de Kock
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, South Africa
| | - Alexander Jetter
- Department of Clinical Pharmacology and Toxicology, University Hospital Zurich, University of Zurich, Switzerland
| | - Pauline Byakika-Kibwika
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
- School of Medicine, Makerere University, Kampala, Uganda
| | - Nadia Eberhard
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Switzerland
| | - Joshua Matovu
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Moses Joloba
- School of Biomedical Sciences, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Daniel Muller
- Department of Clinical Chemistry, University Hospital Zurich, University of Zurich, Switzerland
| | - Yukari C Manabe
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore
| | - Moses R Kamya
- School of Medicine, Makerere University, Kampala, Uganda
| | - Natascia Corti
- Department of Clinical Pharmacology and Toxicology, University Hospital Zurich, University of Zurich, Switzerland
| | - Andrew Kambugu
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Barbara Castelnuovo
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Jan S Fehr
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Switzerland
- Department of Public Health at Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Switzerland
| |
Collapse
|
7
|
The utility of pharmacokinetic studies for the evaluation of exposure-response relationships for standard dose anti-tuberculosis drugs. Tuberculosis (Edinb) 2017. [PMID: 29523331 DOI: 10.1016/j.tube.2017.11.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Tuberculosis (TB) is a major public health problem. Many countries still fall below the minimum World Health Organization (WHO) TB treatment target success rate. There is conflicting evidence about whether concentrations of anti-tuberculosis drugs given at standard doses have an effect on treatment outcomes. The current data correlating anti-TB drug concentrations and treatment outcome is limited. This article summarized the existing literature and their utility in evaluating the association between each anti-TB drug's concentrations using current target concentrations and treatment outcomes in patients with pulmonary tuberculosis receiving standard WHO-recommended dosing.
Collapse
|
8
|
The importance of clinical pharmacokinetic-pharmacodynamic studies in unraveling the determinants of early and late tuberculosis outcomes. ACTA ACUST UNITED AC 2017; 2:195-212. [PMID: 30283633 PMCID: PMC6161803 DOI: 10.4155/ipk-2017-0004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Accepted: 05/16/2017] [Indexed: 12/17/2022]
Abstract
Tuberculosis remains a major infectious cause of morbidity and mortality worldwide. Current antibiotic regimens, constructed prior to the development of modern pharmacokinetic-pharmacodynamic (PK–PD) tools, are based on incomplete understanding of exposure–response relationships in drug susceptible and multidrug resistant tuberculosis. Preclinical and population PK data suggest that clinical PK–PD studies may enable therapeutic drug monitoring for some agents and revised dosing for others. Future clinical PK–PD challenges include: incorporation of PK methods to assay free concentrations for all active metabolites; selection of appropriate early outcome measures which reflect therapeutic response; elucidation of genetic contributors to interindividual PK variability; conduct of targeted studies on special populations (including children); and measurement of PK–PD parameters at the site of disease.
Collapse
|
9
|
Rockwood N, Pasipanodya JG, Denti P, Sirgel F, Lesosky M, Gumbo T, Meintjes G, McIlleron H, Wilkinson RJ. Concentration-Dependent Antagonism and Culture Conversion in Pulmonary Tuberculosis. Clin Infect Dis 2017; 64:1350-1359. [PMID: 28205671 PMCID: PMC5411399 DOI: 10.1093/cid/cix158] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2016] [Accepted: 02/15/2017] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND There is scant evidence to support target drug exposures for optimal tuberculosis outcomes. We therefore assessed whether pharmacokinetic/pharmacodynamic (PK/PD) parameters could predict 2-month culture conversion. METHODS One hundred patients with pulmonary tuberculosis (65% human immunodeficiency virus coinfected) were intensively sampled to determine rifampicin, isoniazid, and pyrazinamide plasma concentrations after 7-8 weeks of therapy, and PK parameters determined using nonlinear mixed-effects models. Detailed clinical data and sputum for culture were collected at baseline, 2 months, and 5-6 months. Minimum inhibitory concentrations (MICs) were determined on baseline isolates. Multivariate logistic regression and the assumption-free multivariate adaptive regression splines (MARS) were used to identify clinical and PK/PD predictors of 2-month culture conversion. Potential PK/PD predictors included 0- to 24-hour area under the curve (AUC0-24), maximum concentration (Cmax), AUC0-24/MIC, Cmax/MIC, and percentage of time that concentrations persisted above the MIC (%TMIC). RESULTS Twenty-six percent of patients had Cmax of rifampicin <8 mg/L, pyrazinamide <35 mg/L, and isoniazid <3 mg/L. No relationship was found between PK exposures and 2-month culture conversion using multivariate logistic regression after adjusting for MIC. However, MARS identified negative interactions between isoniazid Cmax and rifampicin Cmax/MIC ratio on 2-month culture conversion. If isoniazid Cmax was <4.6 mg/L and rifampicin Cmax/MIC <28, the isoniazid concentration had an antagonistic effect on culture conversion. For patients with isoniazid Cmax >4.6 mg/L, higher isoniazid exposures were associated with improved rates of culture conversion. CONCLUSIONS PK/PD analyses using MARS identified isoniazid Cmax and rifampicin Cmax/MIC thresholds below which there is concentration-dependent antagonism that reduces 2-month sputum culture conversion.
Collapse
Affiliation(s)
- Neesha Rockwood
- Department of Medicine, Imperial College London, United Kingdom
- Wellcome Center for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, South Africa
| | - Jotam G Pasipanodya
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, Dallas, Texas
| | - Paolo Denti
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town
| | - Frederick Sirgel
- Department of Science and Technology/National Research Foundation Centre of Excellence for Biomedical Tuberculosis Research/ South African Medical Research Foundation Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Faculty of Health Sciences, Stellenbosch University, Tygerberg
| | - Maia Lesosky
- Wellcome Center for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, South Africa
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, and
| | - Tawanda Gumbo
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, Dallas, Texas
- Department of Medicine, University of Cape Town, South Africa; and
| | - Graeme Meintjes
- Department of Medicine, Imperial College London, United Kingdom
- Department of Medicine, University of Cape Town, South Africa; and
| | - Helen McIlleron
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town
| | - Robert J Wilkinson
- Department of Medicine, Imperial College London, United Kingdom
- Wellcome Center for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, South Africa
- Department of Medicine, University of Cape Town, South Africa; and
- Francis Crick Institute, London, United Kingdom
| |
Collapse
|
10
|
Ramachandran G, Agibothu Kupparam HK, Vedhachalam C, Thiruvengadam K, Rajagandhi V, Dusthackeer A, Karunaianantham R, Jayapal L, Swaminathan S. Factors Influencing Tuberculosis Treatment Outcome in Adult Patients Treated with Thrice-Weekly Regimens in India. Antimicrob Agents Chemother 2017; 61:e02464-16. [PMID: 28242663 PMCID: PMC5404592 DOI: 10.1128/aac.02464-16] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Accepted: 02/09/2017] [Indexed: 11/20/2022] Open
Abstract
The Indian Revised National Tuberculosis (TB) Control Programme uses thrice-weekly treatment with standard drug dosages. The role of plasma drug levels and other factors in determining TB treatment outcomes is not well understood. We aimed to determine the factors influencing the concentrations of rifampin (RMP), isoniazid (INH), and pyrazinamide (PZA) at 2 h postdosing in adult TB patients and to study the factors impacting TB treatment outcome. We recruited 1,912 adult TB patients (newly treated and retreated patients) with pulmonary/extrapulmonary TB receiving antitubercular treatment (ATT) in the RNTCP in Chennai, India. At steady state, the concentrations of RMP, INH, and PZA were determined at 2 h postdosing after supervised drug administration. A total of 1,648 patients had a favorable outcome, while 264 (14%) had an unfavorable outcome. A total of 91%, 16%, and 17% of the patients had suboptimal concentrations of RMP (<8 μg/ml), INH (<3 μg/ml), and PZA (<20 μg/ml), respectively. Factors associated with treatment outcome were low RMP concentrations (adjusted odds ratio [aOR], 0.94; 95% confidence interval [CI], 0.89 to 0.99; P = 0.036), category II ATT (aOR, 2.39; 95% CI, 1.56 to 3.65; P < 0.001), low body weight (aOR, 0.96; 95% CI, 0.94 to 0.98; P < 0.001), alcohol use (aOR, 2.17; 95% CI, 1.42 to 3.31; P < 0.001), male gender (aOR, 1.92; 95% CI, 1.02 to 3.62; P = 0.043), and baseline INH resistance (aOR, 5.74; 95% CI, 3.12 to 10.59; P < 0.001), which significantly increased the likelihood of an unfavorable outcome in multivariate logistic regression analysis. Further studies are needed to optimize anti-TB drug dosages and improve cure rates. Drug susceptibility testing at the baseline and attention to undernutrition and alcohol dependence are other important interventions.
Collapse
|
11
|
Bonnett LJ, Davies GR. Quality of outcome reporting in phase II studies in pulmonary tuberculosis. Trials 2015; 16:518. [PMID: 26566930 PMCID: PMC4644328 DOI: 10.1186/s13063-015-1050-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Accepted: 11/10/2015] [Indexed: 11/29/2022] Open
Abstract
Tuberculosis (TB) remains a major killer amongst the infectious diseases. Current treatment involves a four-drug regimen for at least 6 months. New drugs and regimens are required to shorten treatment duration, reduce toxicity and combat drug resistance, but the optimal methodology to define the critical path for novel regimens is not well defined. We undertook a systematic review to summarise outcomes reported in Phase II trials of patients with newly diagnosed pulmonary TB to assess the need for a core outcome set. A systematic search of databases (PubMed, MEDLINE, EMBASE and LILACs) was conducted on 1 May 2015 to retrieve relevant peer-reviewed articles. Reference lists of included studies were also searched. This systematic review considered all reported outcomes. Risk of bias was considered via sequence generation, allocation concealment, blinding, reasons for exclusions, and selective reporting. Of 55 included studies, 20 were Phase IIB studies based on culture conversion, 32 were Phase IIA studies based on quantitative bacteriology, and three considered alternative outcomes. Large variation in reported outcomes and trial characteristics was observed across the included studies. Bacteriological results were as often expressed in terms of positivity as negativity, with varying definitions of culture conversion. Variation in reporting was particularly marked for Phase IIA studies, where multiple time intervals were typically selected for analysis and sometimes resulted in differing interpretations of the efficacy of drugs or regimens. Within both Phase IIA and IIB studies, there was variation in the time points at which the study participants were sampled, as well as in the bacteriological media and methods used. For successful future meta-analysis of early-phase studies, the findings of this review suggest that development of a core outcome set would be desirable. This would enable trial results to be more easily compared and combined, potentially leading to more effective development of new treatment strategies for patients with TB. Pending development of, and agreement on, such a core outcome set, we suggest some interim recommendations for reporting of future phase II studies of pulmonary tuberculosis.
Collapse
Affiliation(s)
- Laura Jayne Bonnett
- Department of Biostatistics & Department of Clinical Infection, Microbiology & Immunology, University of Liverpool, Waterhouse Building, Block F, 1-5 Brownlow Street, Liverpool, L69 3GL, UK. .,Department of Clinical Infection, Microbiology, & Immunology, University of Liverpool, Ronald Ross Building, 8 West Derby Street, Liverpool, L69 7BE, UK.
| | - Geraint Rhys Davies
- Department of Clinical Infection, Microbiology, & Immunology, University of Liverpool, Ronald Ross Building, 8 West Derby Street, Liverpool, L69 7BE, UK.
| |
Collapse
|
12
|
Wilby KJ, Ensom MHH, Marra F. Review of evidence for measuring drug concentrations of first-line antitubercular agents in adults. Clin Pharmacokinet 2015; 53:873-90. [PMID: 25172553 DOI: 10.1007/s40262-014-0170-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Measurement of drug concentrations and performing therapeutic drug monitoring (TDM) are widely used to optimize efficacy and safety of many commonly used drugs today. Although TDM of first-line antitubercular drugs is used during the treatment of tuberculosis, the extent of any benefit achieved is currently unknown. This review summarizes the available literature describing TDM of first-line treatment agents in patients with tuberculosis and describes clinical associations with achievement of target drug concentrations, including data from special populations. A literature review was conducted for articles describing drug concentration and TDM outcomes for first-line tuberculosis agents in adults. A total of 40 studies were included in the review. Studies were a mixture of controlled trials, observational studies, cross-sectional studies, and case reports. The majority of the studies showed standard dosing does not consistently achieve target concentrations for the first-line antitubercular drugs; however, the clinical implications of this finding are still unclear. Presence of HIV and diabetes mellitus appeared to indicate achievement of lower than target concentrations and this warrants further study in prospective studies. Current published data neither prove nor disprove the utility of TDM for general tuberculosis populations but evidence does not currently support routine measurement of drug concentrations.
Collapse
Affiliation(s)
- Kyle John Wilby
- College of Pharmacy, Qatar University, PO Box 2713, Doha, Qatar,
| | | | | |
Collapse
|
13
|
Exposure to total and protein-unbound rifampin is not affected by malnutrition in Indonesian tuberculosis patients. Antimicrob Agents Chemother 2015; 59:3233-9. [PMID: 25801554 DOI: 10.1128/aac.03485-14] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2014] [Accepted: 03/14/2015] [Indexed: 01/31/2023] Open
Abstract
Nutritional status may have a profound impact on the pharmacokinetics of drugs, yet only few data are available for tuberculosis (TB) drugs. As malnutrition occurs frequently among TB patients, we assessed the effect of malnutrition on the steady-state pharmacokinetics of total and protein-unbound rifampin during the intensive phase of TB treatment. In a descriptive pharmacokinetic study in Bandung, Indonesia, patients received a fixed standard rifampin dose of 450 mg once daily during the intensive phase of TB treatment. A full pharmacokinetic curve for rifampin was recorded, and total and unbound concentrations of rifampin were analyzed in all samples. Rifampin pharmacokinetic parameters were compared between severely malnourished (BMI of <16.0 kg/m(2)), malnourished (BMI of <18.5 kg/m(2)), and well-nourished (BMI of ≥18.5 kg/m(2)) individuals. No difference in total and protein-unbound pharmacokinetic parameters between severely malnourished (n = 7), malnourished (n = 11), and well-nourished (n = 25) patients could be demonstrated. In addition, no significant correlation between BMI and exposure (area under the concentration-time curve from 0 to 24 h [AUC0-24] and maximum concentration of drug in serum [Cmax]) was found. Females had significantly higher total AUC0-24 (geometric mean, 59.2 versus 48.2 h · mg/liter; P = 0.02) and higher unbound AUC0-24 (geometric mean, 6.2 versus 4.8 h · mg/liter; P = 0.02) than males. Overall, a marked 2-fold interindividual variation in the free fraction was observed (7.6 to 15.0%; n = 36). Nutritional status and BMI do not appear to have a major effect on total and protein-unbound pharmacokinetic parameters of rifampin in Indonesian subjects. The large interindividual variability in the free fraction of rifampin suggests that protein-unbound rather than total rifampin concentrations should preferably be used to study exposure-response relationships.
Collapse
|
14
|
Court MH, Almutairi FE, Greenblatt DJ, Hazarika S, Sheng H, Klein K, Zanger UM, Bourgea J, Patten CJ, Kwara A. Isoniazid mediates the CYP2B6*6 genotype-dependent interaction between efavirenz and antituberculosis drug therapy through mechanism-based inactivation of CYP2A6. Antimicrob Agents Chemother 2014; 58:4145-52. [PMID: 24820076 PMCID: PMC4068589 DOI: 10.1128/aac.02532-14] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2014] [Accepted: 05/04/2014] [Indexed: 01/11/2023] Open
Abstract
Efavirenz is commonly used to treat patients coinfected with human immunodeficiency virus and tuberculosis. Previous clinical studies have observed paradoxically elevated efavirenz plasma concentrations in patients with the CYP2B6*6/*6 genotype (but not the CYP2B6*1/*1 genotype) during coadministration with the commonly used four-drug antituberculosis therapy. This study sought to elucidate the mechanism underlying this genotype-dependent drug-drug interaction. In vitro studies were conducted to determine whether one or more of the antituberculosis drugs (rifampin, isoniazid, pyrazinamide, or ethambutol) potently inhibit efavirenz 8-hydroxylation by CYP2B6 or efavirenz 7-hydroxylation by CYP2A6, the main mechanisms of efavirenz clearance. Time- and concentration-dependent kinetics of inhibition by the antituberculosis drugs were determined using genotyped human liver microsomes (HLMs) and recombinant CYP2A6, CYP2B6.1, and CYP2B6.6 enzymes. Although none of the antituberculosis drugs evaluated at up to 10 times clinical plasma concentrations were found to inhibit efavirenz 8-hydroxylation by HLMs, both rifampin (apparent inhibition constant [Ki] = 368 μM) and pyrazinamide (Ki = 637 μM) showed relatively weak inhibition of efavirenz 7-hydroxylation. Importantly, isoniazid demonstrated potent time-dependent inhibition of efavirenz 7-hydroxylation in both HLMs (inhibitor concentration required for half-maximal inactivation [KI] = 30 μM; maximal rate constant of inactivation [kinact] = 0.023 min(-1)) and recombinant CYP2A6 (KI = 15 μM; kinact = 0.024 min(-1)) and also formed a metabolite intermediate complex consistent with mechanism-based inhibition. Selective inhibition of the CYP2B6.6 allozyme could not be demonstrated for any of the antituberculosis drugs using either recombinant enzymes or CYP2B6*6 genotype HLMs. In conclusion, the results of this study identify isoniazid as the most likely perpetrator of this clinically important drug-drug interaction through mechanism-based inactivation of CYP2A6.
Collapse
Affiliation(s)
- Michael H Court
- Individualized Medicine Program, Department of Veterinary Clinical Sciences, Washington State University College of Veterinary Medicine, Pullman, Washington, USA
| | - Fawziah E Almutairi
- Department of Integrative Physiology and Pathobiology, Tufts University School of Medicine, Boston, Massachusetts, USA Program in Pharmacology and Experimental Therapeutics, Sackler School of Graduate Biomedical Sciences, Tufts University, Boston, Massachusetts, USA
| | - David J Greenblatt
- Department of Integrative Physiology and Pathobiology, Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Suwagmani Hazarika
- Department of Integrative Physiology and Pathobiology, Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Hongyan Sheng
- Individualized Medicine Program, Department of Veterinary Clinical Sciences, Washington State University College of Veterinary Medicine, Pullman, Washington, USA
| | - Kathrin Klein
- Dr. Margarete Fischer-Bosch-Institute of Clinical Pharmacology, Stuttgart, and University of Tübingen, Tübingen, Germany
| | - Ulrich M Zanger
- Dr. Margarete Fischer-Bosch-Institute of Clinical Pharmacology, Stuttgart, and University of Tübingen, Tübingen, Germany
| | - Joanne Bourgea
- BD Biosciences, Discovery Labware, Woburn, Massachusetts, USA
| | | | - Awewura Kwara
- Warren Alpert Medical School of Brown University and The Miriam Hospital, Providence, Rhode Island, USA
| |
Collapse
|
15
|
Prahl JB, Johansen IS, Cohen AS, Frimodt-Møller N, Andersen ÅB. Clinical significance of 2 h plasma concentrations of first-line anti-tuberculosis drugs: a prospective observational study. J Antimicrob Chemother 2014; 69:2841-7. [PMID: 25140577 DOI: 10.1093/jac/dku210] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES To study 2 h plasma concentrations of the first-line tuberculosis drugs isoniazid, rifampicin, ethambutol and pyrazinamide in a cohort of patients with tuberculosis in Denmark and to determine the relationship between the concentrations and the clinical outcome. METHODS After 6-207 days of treatment (median 34 days) 2 h blood samples were collected from 32 patients with active tuberculosis and from three patients receiving prophylactic treatment. Plasma concentrations were determined using LC-MS/MS. Normal ranges were obtained from the literature. Clinical charts were reviewed for baseline characteristics and clinical status at 2, 4 and 6 months after the initiation of treatment. At a 1 year follow-up, therapy failure was defined as death or a relapse of tuberculosis. RESULTS Plasma concentrations below the normal ranges were frequently observed: isoniazid in 71%, rifampicin in 58%, ethambutol in 46%, pyrazinamide in 10% and both isoniazid and rifampicin in 45% of the patients. The plasma concentrations of isoniazid correlated inversely with the C-reactive protein level at the time of sampling (P = 0.001). During 1 year of follow-up, therapy failure occurred in five patients. Therapy failure occurred more frequently when the concentrations of isoniazid and rifampicin were both below the normal ranges (P = 0.013) and even more frequently when they were below the median 2 h drug concentrations obtained in the study (P = 0.005). CONCLUSIONS At 2 h, plasma concentrations of isoniazid and rifampicin below the normal ranges were frequently observed. The inverse correlation between the plasma concentrations of isoniazid and C-reactive protein indicate a suboptimal treatment effect at standard dosing regimens. Dichotomization based on median 2 h drug concentrations was more predictive of outcome than dichotomization based on normal ranges.
Collapse
Affiliation(s)
- Julie B Prahl
- International Reference Laboratory of Mycobacteriology, Statens Serum Institut, 5 Artillerivej, 2300 Copenhagen, Denmark
| | - Isik S Johansen
- Department of Infectious Diseases, Copenhagen University Hospital Hvidovre, Kettegård Alle 30, 2650 Hvidovre, Denmark
| | - Arieh S Cohen
- Department of Biochemistry, Immunology and Genetics, Statens Serum Institut, 5 Artillerivej, 2300 Copenhagen, Denmark
| | - Niels Frimodt-Møller
- Department of Clinical Microbiology, Copenhagen University Hospital Hvidovre, Kettegård Alle 30, 2650 Hvidovre, Denmark
| | - Åse B Andersen
- Department of Infectious Diseases, Copenhagen University Hospital Rigshospitalet, 9 Blegdamsvej, 2100 Copenhagen Ø, Denmark
| |
Collapse
|
16
|
Reynolds J, Heysell SK. Understanding pharmacokinetics to improve tuberculosis treatment outcome. Expert Opin Drug Metab Toxicol 2014; 10:813-23. [PMID: 24597717 DOI: 10.1517/17425255.2014.895813] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Tuberculosis (TB) remains the leading cause of death from a curable infectious disease; drug-resistant TB threatens to dismantle all prior gains in global control. Suboptimal circulating anti-TB drug concentrations can lead to lack of cure and acquired drug resistance. AREAS COVERED This review will introduce pharmacokinetic parameters for key anti-TB drugs, as well as the indications and limitations of measuring these parameters in clinical practice. Current and novel methodologies for delivering anti-TB pharmacokinetic-pharmacodynamic data are highlighted and gaps in operational research described. EXPERT OPINION Individual pharmacokinetic variability is commonplace, underappreciated and difficult to predict without therapeutic drug monitoring (TDM). Pharmacokinetic thresholds associated with poor TB treatment outcome in drug-susceptible TB have recently been described and may now guide the application of TDM, but require validation in a variety of settings and comorbidities. Dried blood spots for TDM and prepackaged multidrug plates for minimum inhibitory concentration testing will overcome barriers of accessibility and represent areas for innovation. Operationalizing pharmacokinetics has the potential to improve TB outcomes in the most difficult-to-treat forms of the disease such as multidrug resistance. Clinical studies in these areas are eagerly anticipated and we expect will better define the rational introduction of novel therapeutics.
Collapse
Affiliation(s)
- Jonathan Reynolds
- University of Virginia, School of Medicine , PO Box 801340, Charlottesville, VA 22908-1340 , USA
| | | |
Collapse
|
17
|
Lin HC, Yu MC, Liu HJ, Bai KJ. Impact of food intake on the pharmacokinetics of first-line antituberculosis drugs in Taiwanese tuberculosis patients. J Formos Med Assoc 2014; 113:291-7. [PMID: 24594059 DOI: 10.1016/j.jfma.2014.01.015] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2013] [Revised: 01/18/2014] [Accepted: 01/26/2014] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND/PURPOSE Under the directly observed treatment, short course (DOTS) program, antituberculosis (anti-TB) medications were possibly taken at random time, regardless of whether it was prior to or after meals. This study was to evaluate the impact of food intake on pharmacokinetic profiles of first-line TB drugs in Taiwanese TB patients, as well as the relationship between drug levels and pharmacogenetics. METHODS This open-label, randomized, cross-over study included newly diagnosed Taiwanese TB patients treated between January 2010 and February 2011 at Taipei Medical University-Wan Fang Hospital. Rifater [a fixed-dose combination formulation of isoniazid (INH), rifampicin (RIF), and pyrazinamide (PZA)] and ethambutol (EMB) were given according to national TB guidelines. Blood samples were collected prior to and 1 hour, 2 hours, 4 hours, 6 hours, and 10 hours after dosing under fasting or postprandial conditions. Pharmacokinetic parameters of the maximum serum concentration (Cmax), time to Cmax, and area under the serum concentration-time curve from the beginning to the 10(th) hour (AUC0-10) were calculated. RESULTS Sixteen TB patients were included and received anti-TB treatment under the DOTS program after discharge. The overall effects showed that food intake reduced the mean Cmax (INH: 40.6%, RIF: 40.2%, EMB 34.4%, PZA: 24.4%) and AUC0-10 (INH: 21.3%, RIF: 26.4%, EMB: 12.2%, PZA: 12.0%). Meanwhile, food increased the time to Cmax (INH: 78.1%, RIF: 151.3%, EMB: 41.4%, PZA: 148.9%). CONCLUSION Significantly lower serum drug concentrations were observed under postprandial conditions than fasting conditions for INH, RIF, and PZA. The impact of taking random anti-TB drugs under the DOTS program instead of taking drugs regularly prior to meals requires further study.
Collapse
Affiliation(s)
- Hsien-Chun Lin
- Division of Chest Medicine, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Ming-Chih Yu
- Division of Chest Medicine, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan; School of Respiratory Therapy, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Hsing-Jin Liu
- Division of Hematology and Oncology, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Kuan-Jen Bai
- Division of Chest Medicine, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan; School of Respiratory Therapy, College of Medicine, Taipei Medical University, Taipei, Taiwan.
| |
Collapse
|
18
|
Aarnoutse R, Ruesen C, Burhan E, van Crevel R, Ruslami R. Reply to "strategy to limit sampling of antituberculosis drugs instead of determining concentrations at two hours postingestion in relation to treatment response". Antimicrob Agents Chemother 2014; 58:629-30. [PMID: 24363391 PMCID: PMC3910713 DOI: 10.1128/aac.01651-13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Rob Aarnoutse
- Radboud University Medical Centre, Department of Pharmacy, Nijmegen, The Netherlands
| | - Carolien Ruesen
- Radboud University Medical Centre, Department of Internal Medicine, Nijmegen, The Netherlands
| | - Erlina Burhan
- University of Indonesia, Faculty of Medicine, Department of Pulmonology and Respiratory Medicine, Jakarta, Indonesia
| | - Reinout van Crevel
- Radboud University Medical Centre, Department of Internal Medicine, Nijmegen, The Netherlands
| | - Rovina Ruslami
- University of Padjadjaran, Medical Faculty, Department of Pharmacology and Therapy, Bandung, Indonesia
| |
Collapse
|
19
|
Pasipanodya JG, McIlleron H, Burger A, Wash PA, Smith P, Gumbo T. Serum drug concentrations predictive of pulmonary tuberculosis outcomes. J Infect Dis 2013; 208:1464-73. [PMID: 23901086 DOI: 10.1093/infdis/jit352] [Citation(s) in RCA: 333] [Impact Index Per Article: 30.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Based on a hollow-fiber system model of tuberculosis, we hypothesize that microbiologic failure and acquired drug resistance are primarily driven by low drug concentrations that result from pharmacokinetic variability. METHODS Clinical and pharmacokinetic data were prospectively collected from 142 tuberculosis patients in Western Cape, South Africa. Compartmental pharmacokinetic parameters of isoniazid, rifampin, and pyrazinamide were identified for each patient. Patients were then followed for up to 2 years. Classification and regression tree analysis was used to identify and rank clinical predictors of poor long-term outcome such as microbiologic failure or death, or relapse. RESULTS Drug concentrations and pharmacokinetics varied widely between patients. Poor long-term outcomes were encountered in 35 (25%) patients. The 3 top predictors of poor long-term outcome, by rank of importance, were a pyrazinamide 24-hour area under the concentration-time curve (AUC) ≤ 363 mg·h/L, rifampin AUC ≤ 13 mg·h/L, and isoniazid AUC ≤ 52 mg·h/L. Poor outcomes were encountered in 32/78 patients with the AUC of at least 1 drug below the identified threshold vs 3/64 without (odds ratio = 14.14; 95% confidence interval, 4.08-49.08). Low rifampin and isoniazid peak and AUC concentrations preceded all cases of acquired drug resistance. CONCLUSIONS Low drug AUCs are predictive of clinical outcomes in tuberculosis patients.
Collapse
Affiliation(s)
- Jotam G Pasipanodya
- Office of Global Health, University of Texas Southwestern Medical Center, Dallas, Texas
| | | | | | | | | | | |
Collapse
|
20
|
Isoniazid, rifampin, and pyrazinamide plasma concentrations in relation to treatment response in Indonesian pulmonary tuberculosis patients. Antimicrob Agents Chemother 2013; 57:3614-9. [PMID: 23689725 DOI: 10.1128/aac.02468-12] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Numerous studies have reported low concentrations of antituberculosis drugs in tuberculosis (TB) patients, but few studies have examined whether low drug concentrations affect TB treatment response. We examined steady-state plasma concentrations of isoniazid, rifampin, and pyrazinamide at 2 h after the administration of drugs (C(2 h)) among 181 patients with pulmonary tuberculosis in Indonesia and related these to bacteriological response during treatment. C(2 h) values below reference values for either isoniazid, rifampin, or pyrazinamide were found in 91% of patients; 60% had at least two low C(2 h) concentrations. The isoniazid C2 h was noticeably lower in fast versus slow acetylators (0.9 mg/liter versus 2.2 mg/liter, P < 0.001). At the end of treatment, 82% of the patients were cured, whereas 30 patients (17%) had dropped out during the study, and 2 patients (1%) failed treatment. No association was found between C(2 h) concentrations and sputum culture results at 8 weeks of treatment. Post hoc analysis showed that patients with low pyrazinamide C2 h (P = 0.01) and patients with large extensive lung lesions (P = 0.01) were at risk of at least one positive culture at week 4, 8, or 24/32. Antituberculosis drug concentrations were often low, but treatment response was nevertheless good. No association was found between drug concentrations and 8 weeks culture conversion, but low pyrazinamide drug concentrations may be associated with a less favorable bacteriological response. The use of higher doses of pyrazinamide may warrant further investigation.
Collapse
|
21
|
Pharmacokinetics of first-line tuberculosis drugs in Tanzanian patients. Antimicrob Agents Chemother 2013; 57:3208-13. [PMID: 23629715 DOI: 10.1128/aac.02599-12] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
East Africa has a high tuberculosis (TB) incidence and mortality, yet there are very limited data on exposure to TB drugs in patients from this region. We therefore determined the pharmacokinetic characteristics of first-line TB drugs in Tanzanian patients using intensive pharmacokinetic sampling. In 20 adult TB patients, plasma concentrations were determined just before and at 1, 2, 3, 4, 6, 8, 10, and 24 h after observed drug intake with food to estimate the areas under the curve from 0 to 24 h (AUC0-24) and peak plasma concentrations (Cmax) of isoniazid, rifampin, pyrazinamide, and ethambutol. Acetylator status for isoniazid was assessed phenotypically using the isoniazid elimination half-life and the acetylisoniazid/isoniazid metabolic ratio at 3 h postdose. The geometric mean AUC0-24s were as follows: isoniazid, 11.0 h · mg/liter; rifampin, 39.9 h · mg/liter; pyrazinamide, 344 h · mg/liter; and ethambutol, 20.2 h · mg/liter. The Cmax was below the reference range for isoniazid in 10/19 patients and for rifampin in 7/20 patients. In none of the patients were the Cmaxs for pyrazinamide and ethambutol below the reference range. Elimination half-life and metabolic ratio of isoniazid gave discordant phenotyping results in only 2/19 patients. A substantial proportion of patients had an isoniazid and/or rifampin Cmax below the reference range. Intake of TB drugs with food may partly explain these low drug levels, but such a drug intake reflects common practice. The finding of low TB drug concentrations is concerning because low concentrations have been associated with worse treatment outcome in several other studies.
Collapse
|
22
|
Magis-Escurra C, van den Boogaard J, Ijdema D, Boeree M, Aarnoutse R. Therapeutic drug monitoring in the treatment of tuberculosis patients. Pulm Pharmacol Ther 2011; 25:83-6. [PMID: 22179055 DOI: 10.1016/j.pupt.2011.12.001] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2011] [Revised: 11/11/2011] [Accepted: 12/03/2011] [Indexed: 11/16/2022]
Abstract
At the University Centre for Chronic Diseases Dekkerswald, a tertiary tuberculosis (TB) referral hospital in The Netherlands, therapeutic drug monitoring (TDM) is used in patients in case of relapse TB, when there is delayed response to TB treatment, and when abnormal TB drug concentrations are suspected for other reasons. In this article, a case series is presented to illustrate the value of individualized TB drug dosing in four patients with low TB drug concentrations. Increased doses of the TB drugs, especially of rifampicin, resulted in adequate peak plasma concentrations and improved clinical response to treatment in these patients, while no adverse events occurred.
Collapse
Affiliation(s)
- Cecile Magis-Escurra
- Radboud University Nijmegen Medical Centre, University Centre for Chronic Diseases Dekkerswald, Nijmeegsebaan 31, 6561 KE Groesbeek, The Netherlands.
| | | | | | | | | |
Collapse
|
23
|
Plasma drug activity assay for treatment optimization in tuberculosis patients. Antimicrob Agents Chemother 2011; 55:5819-25. [PMID: 21968363 DOI: 10.1128/aac.05561-11] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Low antituberculosis (TB) drug levels are common, but their clinical significance remains unclear, and methods of measurement are resource intensive. Subjects initiating treatment for sputum smear-positive pulmonary TB were enrolled from Kibong'oto National TB Hospital, Tanzania, and levels of isoniazid, rifampin, ethambutol, and pyrazinamide were measured at the time of typical peak plasma concentration (C(2 h)). To evaluate the significance of the effect of observed drug levels on Mycobacterium tuberculosis growth, a plasma TB drug activity (TDA) assay was developed using the Bactec MGIT system. Time to detection of plasma-cocultured M. tuberculosis versus time to detection of control growth was defined as a TDA ratio. TDA assays were later performed using the subject's own M. tuberculosis isolate and C(2 h) plasma from the Tanzanian cohort and compared to drug levels and clinical outcomes. Sixteen subjects with a mean age of 37.8 years ± 10.7 were enrolled. Fourteen (88%) had C(2 h) rifampin levels and 11 (69%) had isoniazid levels below 90% of the lower limit of the expected range. Plasma spiked with various concentrations of antituberculosis medications found TDA assay results to be unaffected by ethambutol or pyrazinamide. Yet with a range of isoniazid and rifampin concentrations, TDA exhibited a statistically significant correlation with drug level and drug MIC, and a TDA of ~1.0 indicated the presence of multidrug-resistant TB. In Tanzania, low (≤ 2.0) TDA was significantly associated with both lower isoniazid and rifampin C(2 h) levels, and very low (≤ 1.5) TDA corresponded to a trend toward lack of cure. Study of TDA compared to additional clinical outcomes and as a therapeutic management tool is warranted.
Collapse
|
24
|
Use of technetium(99m)-ciprofloxacin scan in Pott's spine to assess the disease activity. INTERNATIONAL ORTHOPAEDICS 2011; 36:271-6. [PMID: 21735206 DOI: 10.1007/s00264-011-1310-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/25/2011] [Accepted: 06/13/2011] [Indexed: 10/18/2022]
Abstract
PURPOSE The World Health Organisation has declared tuberculosis (TB) a global emergency and spinal tuberculosis is one of the most common forms. There is still controversy regarding optimum duration of treatment in osteoarticular tuberculosis due to the lack of well-defined criteria for the end point of treatment. Emergence of multi drug resistant tuberculosis, primarily due to use of poor drug regimens, further illustrates the need of newer and more effective diagnostic methods, particularly in developing countries. METHODS This prospective clinical study to evaluate the role of technetium ((99m)Tc)-ciprofloxacin scan as a tool to assess disease activity involved in 15 cases of TB spine with a mean age of 32.2 years (range 21-72). Following a clinico-radiological diagnosis, all patients were treated with standard anti tubercular treatment and a scan was done at zero, three and six months of treatment with tracer activity being recorded and compared in sequential scans along with a parallel evaluation of clinical and radiological profile at regular intervals. RESULTS Out of 15 cases, nine had an initially positive bone scan. Two patients (22%) converted to negative scans at three months, whereas the remaining seven (78%) turned negative at six months. The end of six months treatment was also accompanied by clinico-radiological resolution in all cases. CONCLUSION In conclusion, technetium ((99m)Tc)-ciprofloxacin scan could be a promising tool for monitoring disease activity in selected cases of tuberculosis spine as an alternative for therapeutic drug monitoring; however, due to the small sample size, studies with a large number of patients might be of help in defining these cases in a better way.
Collapse
|
25
|
Ramachandran G, Kumar AKH, Swaminathan S. Pharmacokinetics of anti-tuberculosis drugs in children. Indian J Pediatr 2011; 78:435-42. [PMID: 21165722 DOI: 10.1007/s12098-010-0304-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2010] [Accepted: 11/23/2010] [Indexed: 10/18/2022]
Abstract
Tuberculosis (TB) is among the top 10 causes of death among children worldwide. Recent reports suggest that the currently recommended dosages of first-line anti-TB drugs are not adequate in children, particularly younger children. The objective of this review was to synthesize available pharmacokinetic data of anti-TB drugs in children from different settings that would help determine optimal doses of anti-TB drugs, in order to provide evidence-based recommendations. A PubMed database was searched from 1970 to present using the terms rifampicin, isoniazid, pyrazinamide, ethambutol, pharmacokinetics, HIV, TB, nutrition and children. References from identified articles were also reviewed and abstract from recent meetings were included. Available pharmacokinetic data from different settings suggest that age, nutritional status, HIV infection and gene polymorphisms in drug metabolising enzymes could significantly influence the pharmacokinetics of first-line anti-TB drugs. However, most of the pharmacokinetic studies conducted so far in children have failed to associate drug concentrations with treatment outcomes. Hence, more studies to examine the relationship between drug pharmacokinetics and response to anti-TB treatment are required. Studies to examine the impact of nutritional status and HIV infection on the pharmacokinetics of anti-TB drugs in children are needed.
Collapse
Affiliation(s)
- Geetha Ramachandran
- Tuberculosis Research Centre (Indian Council of Medical Research), Chennai, India
| | | | | |
Collapse
|
26
|
Heysell SK, Moore JL, Keller SJ, Houpt ER. Therapeutic drug monitoring for slow response to tuberculosis treatment in a state control program, Virginia, USA. Emerg Infect Dis 2011; 16:1546-53. [PMID: 20875279 PMCID: PMC3294393 DOI: 10.3201/eid1610.100374] [Citation(s) in RCA: 112] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
TOC summary: Diabetes was associated with increased risk for slow response and low rifampin levels. Therapeutic drug monitoring may be useful in tuberculosis management, but programmatic implementation is understudied. We performed a retrospective cohort study to determine prevalence of lower than expected levels of isoniazid, rifampin, ethambutol, and pyrazinamide measured at time of estimated peak serum concentration. Patients were tested for serum concentration at 2 hours after medication administration. When patients were tested, 22 had concentrations lower than expected range for rifampin, 23 of 39 patients had low levels of isoniazid, and 8 of 26 patients had low levels of ethambutol; all 20 patients tested for pyrazinamide were within expected range. Over 26 months, 42 patients met criteria for slow response. Diabetes was associated with slow response (p<0.001), and persons with diabetes were more likely than persons without diabetes to have low rifampin levels (p = 0.03). Dosage adjustment of rifampin was more likely to elevate serum concentration to the target range than adjustment of isoniazid given in daily doses (p = 0.01).
Collapse
Affiliation(s)
- Scott K Heysell
- Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia 22908, USA.
| | | | | | | |
Collapse
|
27
|
Schaaf HS, Willemse M, Cilliers K, Labadarios D, Maritz JS, Hussey GD, McIlleron H, Smith P, Donald PR. Rifampin pharmacokinetics in children, with and without human immunodeficiency virus infection, hospitalized for the management of severe forms of tuberculosis. BMC Med 2009; 7:19. [PMID: 19386087 PMCID: PMC2679060 DOI: 10.1186/1741-7015-7-19] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2009] [Accepted: 04/22/2009] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Rifampin is a key drug in antituberculosis chemotherapy because it rapidly kills the majority of bacilli in tuberculosis lesions, prevents relapse and thus enables 6-month short-course chemotherapy. Little is known about the pharmacokinetics of rifampin in children. The objective of this study was to evaluate the pharmacokinetics of rifampin in children with tuberculosis, both human immunodeficiency virus type-1-infected and human immunodeficiency virus-uninfected. METHODS Fifty-four children, 21 human immunodeficiency virus-infected and 33 human immunodeficiency virus-uninfected, mean ages 3.73 and 4.05 years (P = 0.68), respectively, admitted to a tuberculosis hospital in Cape Town, South Africa with severe forms of tuberculosis were studied approximately 1 month and 4 months after commencing antituberculosis treatment. Blood specimens for analysis were drawn in the morning, 45 minutes, 1.5, 3.0, 4.0 and 6.0 hours after dosing. Rifampin concentrations were determined by liquid chromatography tandem mass spectrometry. For two sample comparisons of means, the Welch version of the t-test was used; associations between variables were examined by Pearson correlation and by multiple linear regression. RESULTS The children received a mean rifampin dosage of 9.61 mg/kg (6.47 to 15.58) body weight at 1 month and 9.63 mg/kg (4.63 to 17.8) at 4 months after commencing treatment administered as part of a fixed-dose formulation designed for paediatric use. The mean rifampin area under the curve 0 to 6 hours after dosing was 14.9 and 18.1 microg/hour/ml (P = 0.25) 1 month after starting treatment in human immunodeficiency virus-infected and human immunodeficiency virus-uninfected children, respectively, and 16.52 and 17.94 microg/hour/ml (P = 0.59) after 4 months of treatment. The mean calculated 2-hour rifampin concentrations in these human immunodeficiency virus-infected and human immunodeficiency virus-uninfected children were 3.9 and 4.8 microg/ml (P = 0.20) at 1 month after the start of treatment and 4.0 and 4.6 microg/ml (P = 0.33) after 4 months of treatment. These values are considerably less than the suggested lower limit for 2-hour rifampin concentrations in adults of 8.0 microg/ml and even 4 microg/ml CONCLUSION Both human immunodeficiency virus-infected and human immunodeficiency virus-uninfected children with tuberculosis have very low rifampin serum concentrations after receiving standard rifampin dosages similar to those used in adults. Pharmacokinetic studies of higher dosages of rifampin are urgently needed in children to assist in placing the dosage of rifampin used in childhood on a more scientific foundation.
Collapse
Affiliation(s)
- Hendrik Simon Schaaf
- Department of Paediatrics and Child Health, Faculty of Health Sciences, Stellenbosch University and Tygerberg Children's Hospital, PO Box 19063, Tygerberg 7505, South Africa
| | - Marianne Willemse
- Department of Paediatrics and Child Health, Faculty of Health Sciences, Stellenbosch University and Tygerberg Children's Hospital, PO Box 19063, Tygerberg 7505, South Africa
| | - Karien Cilliers
- Department of Human Nutrition, Faculty of Health Sciences, Stellenbosch University, Tygerberg 7505, South Africa
| | - Demetre Labadarios
- Department of Human Nutrition, Faculty of Health Sciences, Stellenbosch University, Tygerberg 7505, South Africa
- Knowledge Systems, Human Sciences Research Council, Private Bag X9182, Cape Town 8000, South Africa
| | - Johannes Stephanus Maritz
- Division of Molecular Biology and Human Genetics and the Medical Research Council Centre for Molecular and Cellular Biology, Department of Science and Technology/National Research Foundation Centre of Excellence for Biomedical Tuberculosis Research, Faculty of Health Sciences, Stellenbosch University, PO Box 19063, Tygerberg 7505, South Africa
| | - Gregory D Hussey
- Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Rondebosch 7701, South Africa
| | - Helen McIlleron
- Division of Clinical Pharmacology, University of Cape Town, Rondebosch 7701, South Africa
| | - Peter Smith
- Division of Clinical Pharmacology, University of Cape Town, Rondebosch 7701, South Africa
| | - Peter Roderick Donald
- Department of Paediatrics and Child Health, Faculty of Health Sciences, Stellenbosch University and Tygerberg Children's Hospital, PO Box 19063, Tygerberg 7505, South Africa
- Division of Molecular Biology and Human Genetics and the Medical Research Council Centre for Molecular and Cellular Biology, Department of Science and Technology/National Research Foundation Centre of Excellence for Biomedical Tuberculosis Research, Faculty of Health Sciences, Stellenbosch University, PO Box 19063, Tygerberg 7505, South Africa
| |
Collapse
|